TNMAC Registration Form 2016

Step 1 of 3 - TNMAC Registration

Kids Camp: Please note that Earicles provides childcare coverage for up to 2 children per family, 2 years of age and over during the Saturday morning conference lectures. Each additional child (2 years of age and over) is an additional $50 fee. If you need childcare coverage for a child under 2 лет, please email us at info@lewinmd.com and we can refer you to a childcare service.

Check here if the patient above is attending Kids Camp

Please fill out the information below for all other attendees (Mother, Father, Sibling, и т.д.. ) (click the “ ” sign for each new person):

Первый

Последний

Relationship to patient

Age if a minor on 8/6/2016

Attending Kids Camp? Y/N

Patient has (choose all that apply):

Right Microtia

Right Atresia

Left Microtia

Left Atresia

Гемифациальная микросомия

Jaw concerns

Treacher Коллинз синдром

Facial Nerve weakness/paralysis

Other concern (fill in)

Конкретного пациента назначениям с хирургами (IPAs)

It is important to Dr. Левин, Доктор. Kesser, and Dr. Bonilla that TNMAC attendees are able to schedule Individual Patient Appointments (IPAs) with the surgeons if desired. IPAs will take place on Saturday, August 6th afternoon and evening. IPAs will be scheduled on a first-come, first-served basis.

Please check which of the surgeons you would like to speak with:

Доктор. Шерил Левин (Porous Implant Ear Reconstruction for Microtia)

Доктор. Артуро Bonilla (Rib Cartilage Reconstruction for Microtia)

Доктор. Брэдли Кессер (Atresia Repair)

The exact IPA time(с) will be emailed to you one week prior to TNMAC.*PLEASE NOTE: IPAs are meant to be an INTRODUCTION to the surgeons and an opportunity for them to examine the patient. PLEASE UNDERSTAND, to fairly accommodate all families, IPAs are strictly 10 minutes long, and if you are late, you may not be able to reschedule with the surgeon. Однако, all of the surgeons anticipate continuing discussions with families to answer specific questions or to review CT scans in detail in the weeks and months after the conference (at no charge). В дополнение, you will have the opportunity to interact with the surgeons during the Friday night Meet &amp; Greet Reception.

Payment Information: The TNMAC Registration Fee is $95 per family (2 adults + 2 children) and includes all items listed on the Program. Each additional adult is an additional $50 fee. Each additional child attending Kids Camp is an additional $50.
Please update your shopping cart appropriately:

Conference Registration Fee (includes 2 adults, 2 children)

Price:$95.00

Each Additional Adult $50 each (Max of 2)

0 Additional Adult

1 Additional Adult

2 Additional Adults

Extra Kids Camp Fee $50 each (Max of 2)

0 Additional Child

1 Additional Child

2 Additional Children

Comments/Questions

Total

$0.00

Cancellation Policy: Unfortunately, we cannot refund any cancellations. If you do not attend the conference, your fee will be considered a tax-deductible donation to Earicles and upon request a letter will be sent to you documenting the donation. Please email info@lewinmd.com with any questions about this policy.

After clicking "Submit and Pay" you will be directed to PayPal. You may use a PayPal account or any major credit card to pay. Your confirmation email will include a link to book discounted hotel accommodations.